Eur Child Adolesc Psychiatry (2015) 24:219–225 DOI 10.1007/s00787-014-0568-1
ORIGINAL CONTRIBUTION
National total Survey of German adolescent Suicide in Prison D. Radeloff • T. Lempp • E. Herrmann M. Kettner • K. Bennefeld-Kersten • C. M. Freitag
•
Received: 16 February 2014 / Accepted: 26 May 2014 / Published online: 22 June 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Incarcerated adolescents are a high-risk group for suicidal behaviour, but data on completed suicide are scarce in this population. The present study aimed at calculating relative risks (RR) of suicide in detention and identifying age-related risk factors. We compared data of a German national total survey of completed suicide of young detainees (14 to \21 years, N = 79) during the years 2000–2010 with age- and gender-adjusted suicide deaths in non-incarcerated adolescents (N = 3,484) and incarcerated adults (N = 781). Prison suicide accounted for 2.3 % of all suicide deaths in adolescents, but only 0.1 % of this age group was detained. The RR = 23.0 for adolescent suicide in detention exceeded the RR = 7.7 of adults by far. In adults, suicide rates in pre-trial detention was fivefold higher than in criminal detention; suicide rates were more balanced in adolescent detainees. Our results
D. Radeloff and T. Lempp contributed equally to this work. D. Radeloff (&) T. Lempp C. M. Freitag Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Goethe University of Frankfurt, Deutschordenstrasse 50, 60528 Frankfurt, Germany e-mail: [email protected] E. Herrmann Department of Medicine, Institute of Biostatistics and Mathematical Modeling, Goethe University Frankfurt, Frankfurt, Germany
underline the need for age-specific suicide prevention strategies in detention. Keywords Suicide Detention Risk assessment Mortality Conduct disorders Community mental health Abbreviations SR Suicide rate = suicide deaths per 100,000 person years RR Relative risk = ratio of the probability of an event occurring in an exposed group to the probability of the event occurring in a comparison group Group YP Adolescents (14 to \21 years of age) in criminal detention or pre-trial detention (p = prison) Group YGP Adolescents (14 to \21 years of age) in the general population (GP) outside correctional facilities Population Group YP ? Group YGP = adolescents (14 Y to \21 years of age) Group AP Adults (C21 years of age) in criminal detention or pre-trial detention (p = prison) Group AGP Adults (C21 years of age) in the general population (GP) outside correctional facilities Population Group AP ? Group AGP = adults A (C21 years of age)
M. Kettner Institute of Forensic Medicine, University of Saarland Medical School, Homburg/Saar, Germany
Introduction
K. Bennefeld-Kersten Criminological Services, Institute of Justice in Lower Saxony, Celle, Germany
In most western countries, suicide is the second or third leading cause of death among people 15–20 years old
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[1–3], and prevention has been challenging [4]. Incarcerated adolescents constitute a high-risk group for suicidal behaviour, and completed suicide was reported to be the leading cause of death in juvenile justice facilities [5]. Different reasons may contribute to the elevated suicide behaviour in young offenders. First, a high percentage of incarcerated youth shows characteristics, which are associated with high risk for suicide in the general population, for example substance abuse or mental disorders [6–8]. Second, additionally to this ‘imported’ risk profile, facility environment itself may contribute to an elevated suicide risk in confinement, as inhabitants are challenged by stressful conditions [5, 9]. Most likely due to a combination of these factors, suicidal ideation, plans and attempts are much more common in incarcerated youth compared to data from age-adapted general population [10–12]. While there is a comprehensive body of the literature on suicidal ideation and suicide attempts in adolescent inmates, studies on completed underage prison suicide are scarce. It is far from resolved, if suicide attempters and suicide completers are comparable with regard to psychopathology and risk factors [13, 14]. To the best of our knowledge, only one study [15] provides robust estimates of relative risks (RR) of teenage suicide in detention, and reported an 18-fold increased risk compared to the general population in Great Britain. Other studies reported a threefold, respectively, 4.6-fold increased risk [5, 16], but lacked precisely agematched data of the general population. The present study includes all known cases of completed suicide of adolescents and young adults (14 to \21 years), committed in German pre-trial and criminal detentions during the years 2000–2010. To provide robust RRs of adolescent suicide in detention and to describe age-specific risk factor profiles, data were compared with epidemiological data on incarcerated and non-incarcerated agematched adolescents and young adults, and on incarcerated adults (C21 years of age). We hypothesize (1) that detained German adolescents will show an increased suicide risk compared to non-incarcerated adolescents, (2) that RRs for suicide in detention will be greater in adolescents than in adults, and (3) that adolescent suicide rates will show age-related specifics regarding potential risk factors like gender or modus of detention.
Methods German youth-crime laws and prison system Across western countries, the age of criminal responsibility (the age at which the criminal justice system can prosecute a child or adolescent for a crime, as it is considered capable of understanding the wrongfulness of its conduct) and the
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age of criminal majority (the age at which the criminal justice system processes offenders as adults) vary considerably [17]. Most European countries have defined ages of criminal responsibility at between 13 and 16 years, whereas Cyprus assume criminal responsibility at the age of 7 years and the British legal system comprises varying ages (Scotland at 8 years; Northern Ireland, England and Wales at 10 years). The age of criminal majority is 18 in most European countries [17]. According to German law, the age of criminal responsibility is 14 years and there is a particular criminal law relating to young offenders between 14 and \18 years. Between 18 and 21 years of age, the courts have the provision to transfer offenders to the juvenile criminal law, depending on emotional, mental, and intellectual maturity [18]. Individuals who are 21 years old or older are judged as fully criminal responsible irrespective of possible maturational lags and are usually detained in correctional institutions for adults. Based on this differentiation, we studied 14 year to \21-year-old individuals as one group and compared these with adults aged 21 years and above. Data RRs for prison suicide were calculated based on: (1) the number of suicide deaths, and (2) the number of persons in justice facilities, (3) the number of suicide deaths, and (4) the number of persons in the general population. Data were obtained for comparable age strata, gender and time periods. Age strata were chosen as described above. Data were obtained for the 11-year period, 2000–2010. Adolescents and young adults were merged and labelled Population Y (Youth and Young Adults, 14 to \21 years), comprising minors and young adults in pre-trial detention or criminal detention (Group YP, p = prison) and those in the general population outside correctional facilities (Group YGP, GP = general population). Population A (Adults) consisted of adults who were at least 21 years of age, comprising pre-trial and criminal detainees (Group AP) and adults in the general population outside correctional facilities (Group AGP). In Germany, every state (Bundesland) is obliged to report all cases of suicide in prison. On a national level, data of committed suicides in incarcerated adolescents and adults were collected by one of the co-authors (KBK) by analysing the reports of unusual events of all pre-trial and criminal detentions in Germany retrospectively in the given time period at the Kriminologischer Dienst des Bildungsinstituts des niedersa¨chsischen Justizvollzuges in Celle/ Germany. Data from forensic psychiatry departments were not taken into account in this study. Data on demographic characteristics of individuals placed in correctional facilities in Germany were provided
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by the biannual census of the Federal Statistical Office Germany. Census data provide the number of inmates on two predefined dates per year, which were used to calculate the number of person years spent in detention during the study period. In this study, we compared person years spent inside and outside of correctional facilities. General population annual suicide deaths and annual population census data were obtained from the scientific section of the Federal Statistical Office Germany (Forschungsdatenzentrum der Statistischen Landesa¨mter, Duesseldorf, Germany). The study was approved by the ethics committee of the medical faculty of Goethe University Frankfurt, Germany and has been performed in accordance with the ethical standards of the Declaration of Helsinki and its later amendments.
Results
Statistical methods
During the 11-year study period, 733,041 person years were spent in detention in Germany covering all age groups. Group YP spent 69,863 person years in detention. In Group YP, 66,844 person years (95.7 %) were spent by male prisoners, and 3,019 (4.3 %) person years were spent by female prisoners. In pre-trial detention, 25,004 (35.8 %), and in criminal detention, 44,859 (64.2 %) person years were spent. Group AP spent 663,178 person years in detention; 625,473 (94.3 %) person years accounted for male prisoners, 37,705 (5.7 %) person years accounted for female prisoners. In Group AP 137,721 (20.8 %) person years were spent in pre-trial detention, and 525,457 (79.2 %) person years were spent in criminal detention.
Data were analysed with R (Version 3.0.2, URL:http:// www.R-project.org; [19, 20]). Suicide deaths inside and outside detention as well as the number of person years spent inside and outside detention were given in 2 9 2-tables stratified for age, gender and modus of confinement. Data were tested for an association between suicide and imprisonment with the Chi-square/Fisher exact test. Suicide rates (SR = number of suicides/number of 100,000 person years) and relative risks (RR = SR in exposed population/SR in non-exposed population) were calculated for the imprisoned and general population stratified by age (Population Y, A), gender and modus of confinement (pre-trial detention, criminal detention). To test for differences in the association between suicide and imprisonment between both age groups, 2 9 2-tables of Group YP and Group AP were compared, using the Tarone test for heterogeneity. Values of P \ 0.05 were considered significant; values P \ 0.10 were considered as a trend. To test for age specificity of risk factors (gender, modus of confinement), 2 9 2-tables for both age groups of prisoners were compared. First, 2 9 2-tables with the variables gender (male/female) and suicide (suicide/no suicide) were compared, using the Tarone test for heterogeneity. In a second step, 2 9 2-tables with the variables modus of confinement (pre-trial detention, criminal detention) and suicide were compared using the same approach. Trends in time were calculated for adolescents and young adults in detention and in the general population using linear regression with SRs on time period. Also, relative risks for adolescent suicide in detention were tested for time trends.
In Population Y prison suicide accounted for 2.3 % of all suicides, but only 0.1 % of this age group was detained. In Population A prison suicide accounted for 0.7 % of all suicides, albeit only 0.1 % of this age group was in detention. Between 2000 and 2010, the sum of person years spent inside or outside of correctional facilities by the general population (C14 years of age) was 785,124,951. Population Y spent 70,973,545 person years in the examined time period. Among these, 39,606,661 person years accounted for minors (\18 years). In Population A, 714,151,406 person years were spent in total. Population in detention
Suicide within detention In Group YP (adolescent prisoners), 79 cases of prison suicide occurred during the study period. All cases of suicide were male. Among them, 36 suicides (45.6 %) occurred in pre-trial detention and 43 (54.4 %) occurred in criminal detention. In group YP, the SR was 113.1 (minors: 83.94). SR in males was 118.2, in females 0.0. SR in pretrial detention and criminal detention was 144.0 and 95.9, respectively. In Group AP (adult prisoners), the number of suicides was 781. Among them, in 763 (97.7 %) cases gender was male and in 18 (2.3 %) cases, gender was female. N = 441 suicides (56.5 %) happened in pre-trial detention and 340 (43.5 %) in criminal detention. In Group AP, the SR was 117.8. In males, SR was 122.0; in females SR was 47.7. SR in pre-trial detention and criminal detention was 320.2 and 64.7, respectively. Please consider Table 1 as a summary of SRs in detention.
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Table 1 Suicide rates (SR) and relative risks (RR) in incarcerated and non-incarcerated adolescents and adults Gender Both genders
Adolescents
Detention No detention
Adults
Detention No detention
Males
Adolescents Adults
Females
Adolescents Adults
Detention
SR
P (v2/fisher)a)
RR (95 % CI)
P (Tarone)
113.1
\0.001
23.0 (17.2, 30.8)
\0.001
\0.001
7.7 (7.1, 8.4)
\0.001
16.0 (11.9, 21.4)
\0.001
5.2 (4.8, 5.7)
1
–
\0.001
6.1 (3.3, 11.1)
4.9 117.8 15.3 118.2
No detention
7.4
Detention No detention
122.0 23.4
Detention
0.0
No detention
2.3
Detention No detention
47.7
\0.001
0.515
7.8
SR suicide rate (number of suicides/100,000 person years), RR relative risk, CI confidence interval, Tarone Tarone test for heterogeneity a
Fisher exact test was conducted when cells with expected zero counts were present in underlying 2 9 2-tables
Population and suicides outside detention Outside correctional facilities, 70,903,603 person years (males: 36,306,347, 51.2 %; females: 34,598,992, 48.8 %), were spent by adolescents and young adults. In Group YGP, 39,591,160 person years (males: 20,313,280 person years, 51.3 %; females: 19,277,880 person years, 48.7 %) accounted for minors. In Group AGP, 713,487,447 person years (males: 344,406,324 person years, 48.3 %; females: 369,081,123 person years, 51.7 %) were spent. In Group YGP, the total number of suicides was 3.484; 1.210 suicides occurred in minors (\18 years; 34.7 %). In 2,686 (77.1 %) cases, gender was male, in 798 (22.9 %) cases, gender was female. In Group YGP, the SR was 4.9 (minors: 3.1). SR in males was 7.4 and in females the SR was 2.3. In Group AGP, the total number of suicides was 109,472. Among these, 73.9 % were male (N = 80,846) and 26.1 % were female (N = 28,966). In Group AGP, the SR was 15.3. SR in males was 23.4 and in females SR was 7.8. Please consider Table 1 for SRs in the general population. Relative risks and group comparisons Comparing Group YP and Group YGP, a RR of 23.0 for completed suicide was observed which equals to a 23-fold increased suicide risk in young prisoners when compared with the same age group of the general population. In minors, the RR was 27.5. Comparing Group AP and AGP, the RR was 7.7, which equals to a 7.7-fold increased risk of suicide in prison in this age group. In detained adolescents and young adults, the RR for suicide was significantly
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greater than in incarcerated adults (Tarone test for heterogeneity: v2 = 93.38, df = 1, P \ 0.001). Gender Male gender was associated with suicide in all groups (Group YP: df = 1, P = 0.051 (Fisher test); Group AP: v2 = 603.45, df = 1, P \ 0.001; Group YGP: v2 = 992.62, df = 1, P \ 0.001; Group AGP: v2 = 28,608.38, df = 1, P \ 0.001). The gender-specific RR (Group YP compared to Group YGP) was 16.2 for males and 0.00 for females. In adults, the RR (Group AP compared to Group AGP) was 5.2 for males and 6.1 for females, which indicates a roughly equal RR between the gender groups. Indeed, the association between gender and prison suicide did not differ significantly between age groups (Tarone test for heterogeneity: v2 = 1.40, df = 1, P = 0.237). Modus of confinement SRs in pre-trial and criminal detention are given in Table 2. In pre-trial detention, the relative risk in Group YP was RR = 29.3 (Group AP : 20.9) and in criminal detention the RR was 19.5 (Group AP: 4.2). In the imprisoned population, the modus of confinement had a different influence on suicides in Group AP as compared to Group YP (Tarone test for heterogeneity: v2 = 27.42, df = 1, P \ 0.001): In adult prisoners, suicide was associated stronger with pre-trial detention (SR = 320.2) than with criminal detention (SR = 64.7), whereas in adolescents and young adults, the influence of modus of confinement was more balanced (pre-trial detention: SR = 144.0; criminal detention:
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Table 2 Suicide rates (SR) in pre-trial and criminal detention in incarcerated adolescents and adults Modus of confinement Adolescents
Adults
SR
P (v2)
RR (95 % CI)
P (Tarone)
Pre-trial detention
144.0
0.090
1.5 (0.8, \0.001 2.7)
Criminal detention
95.9
Pre-trial detention
320.2 \0.001
Criminal detention
64.7
4.9 (4.1, 6.0)
SR suicide rate (number of suicides/100,000), RR relative risk, CI confidence interval, Tarone Tarone test for heterogeneity
SR = 95.9). Comparing Population Y and Population A, the association between criminal detention and suicide was significantly stronger in Population Y (Tarone test for heterogeneity: v2 = 107.15, df = 1, P \ 0.001). Trend in time In adolescents, all cases of suicides were male. Therefore, trend over time for SRs in detention and in the general population were calculated for male gender. There was a significant decrease of SRs in adolescent detainees (Group YP: R2 = 0.38, t = -9.3, df = 9, P = 0.042) and adolescents in the general population (Group YGP: R2 = 0.55, t = -0.29, df = 9, P = 0.009). No significant trend over time was found for RR of suicide in adolescent detainees (Population Y: R2 = -0.173, t = -0.71, df = 9, P = 0.203).
Discussion This study has shown the following main findings: (1) The RR for suicide of adolescents in detention in Germany is 23.0, indicating a 23-fold increased risk for suicide of this group compared to the age-matched general population. (2) Compared to adults (RR = 7.7), the RR was significantly greater in adolescents. (3) The association between suicide and modus of confinement was age-dependent: In the imprisoned population, the influence of criminal detention and pre-trial detention on suicide was roughly equal in adolescents, whereas in adulthood, suicide was associated stronger with pre-trial detention.
equivalent general population was in confinement. The RR for suicide of adolescent and young adult detainees was 23.0. This is in accordance with our first hypothesis, and proves that young prisoners constitute a high-risk group for completed suicide. Men are by far overrepresented in imprisoned populations (in this study, 94.4 % of the detainees were male), and male gender is associated with a higher suicide risk. Thus, male gender contributes to a high RR in detention. As male-specific RR is also high in young detainees (RR = 16.0), additional factors may contribute to the elevated suicide risk in young prisoners: Firstly, many detainees are high-risk adolescents who would even have been at a high risk for suicide without being incarcerated. For example, impulsive character traits and mental disorders [6, 7], substance abuse [21] and history of prior suicide attempts [10] are substantially more common in adolescents in detention compared to the age-equivalent general population. Secondly, the detention environment itself (e.g. separation from family and pears, loss of control and perspective, feelings of shame and guilt) might contribute to a high risk of suicide compared to the adolescents’ environment outside detention [5, 9, 22]. To our knowledge, only one study [15] provides robust data of suicide risk in adolescent prisoners, remarkably standard mortality ratios were calculated. Male prisoners in the United Kingdom showed an 18-fold increased suicide risk between 15 and \18 years of age, and a sixfold increased suicide risk between 18 and 20 years. No adolescent female suicide occurred in the examined population [23]. As data on adolescent suicide are always based on a small number of prison suicides, the authors recommended a replication of their findings. Our results replicated an elevated RR in young prisoners. Two other studies reported lower RRs in contrast to our results: Gallagher and Dobrin reported a threefold [5] and Memory a 4.6-fold [16] increase in suicide risk in adolescent detainees. In both US–American studies, the number of included suicide cases was low (Gallagher: N = 20, Memory: N = 28), and no precise age matching or calculation of gender-specific RRs were conducted. Gallagher examined suicide rates in a mixed sample of detainees in both, open and secure juvenile justice facilities in the US. The smaller RR found in this study might also reflect lower suicide rates in open juvenile correction facilities, which were excluded in our study. Comparison of RR in adolescents and adults
RR in young detainees Between 2000 and 2010, prison suicides accounted for 2.2 % of all suicide deaths in Germany in the age band from 14 to \21 years, whereas only 0.1 % of the age-
The association between suicide and detention was significantly stronger in adolescents compared to adults, reflected by a higher RR in the younger age group. This finding is in accordance to previous studies reporting
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standard mortality ratios of different age groups in detention [15, 23]. Standard mortality ratios in male minor detainees were highest of all age groups followed by male young adults (18–21 years). In agreement, in our study, RR was highest for male minors and second highest in male young adults. As data in adolescents are based on a small number of suicides in both studies, results need to be treated with caution. The difference of RR between adolescents and adults was mainly driven by different SRs in the general population with lower rates in adolescents, whereas SRs in detention were roughly equal between adolescents and adults. Different factors might contribute to the higher RR in young prisoners relative to adult prisoners. First, the high RR in adolescent detainees might be influenced by a disproportionately high amount of late adolescents (18–21 years) in prison compared to the general population. Secondly, age-related differences in criminal law result in age-specific characteristics of imprisoned populations, e.g. regarding duration of detention or severity of offences [24]. Thirdly, young detainees could be particularly challenged by detention environment due to a higher vulnerability to detention-specific stressors (e.g. separation from family) and immature coping strategies. Compared to adult detainees, the amount of prisoners experienced with prior detention is lower in adolescent detainees [24]. Gender The difference between RR of all detainees compared to gender-specific RRs emphasizes the necessity to take characteristics of the incarcerated and the general population into account when calculating or comparing RRs of high-risk populations. RR for male prisoners in adolescence was 15.6. No female prisoners committed suicide in this age group. This is in accordance with other studies, reporting that in teenage years, prison suicide is committed mainly by males [9, 15, 23]. The lack of female adolescent suicide reflects the high percentage of male prisoners in confinement: As the portion of incarcerated females in this age group is low, the calculation of underage female suicide ratios fails for statistical reasons [23]. In all groups, male gender was associated with suicide (in adolescent prisoners, this association was found only as a trend, possibly due to a small sample size). As the association between gender and suicide was not significantly different between age groups, gender can not be considered as an age-specific risk factor. Because data on female suicide in confinement is rare, we suggest a metaanalytic approach on pooled data in future work.
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Modus of confinement In both age groups, detention was associated with an elevated risk for suicide. In both young detainees and adults, SRs were higher in pre-trial detention compared to criminal detention. To our knowledge, this is the first study that compared RRs for adolescent and young adult suicide in pre-trial versus criminal detention. Previous studies reported that juvenile prison suicide characteristics were influenced by the modus of detention as suicide rates differed between open and secure juvenile correction facilities with lower rates in open facilities [5, 16]. The time point of suicide was influenced by the modus of detention: in detention centres most suicides happened within the first week after confinement compared to less secure juvenile correctional facilities [25]. Still, results were based on small samples and differing methodological frameworks, leading to partly contradictory results between studies [16, 25]. In our study, we found balanced SRs in adolescent pretrial (SR = 144.0) and criminal detainees (SR = 95.9), whereas in adulthood, the SR in pre-trial detention (SR = 320.2) was fivefold greater than in criminal detention (SR = 64.7). Thus, in young prisoners criminal detention must be considered as an age-specific risk factor nearly as important as pre-trial detention. This is in accordance with our third hypothesis. Still, this study does not provide information about the reasons for this finding, thus causations stay speculative. Two high-risk periods for suicide in pre-trial detention were described [26]: frequently, suicides occur at a very early stage of confinement or within 3 days of a court appearance, especially when a conviction and harsh sentencing can be anticipated. Speculative, in juvenile pre-trial detention, the level of care may be higher during reception and first night procedures than in adult justice facilities. Less harsh penalties due to youth crime law may result in lower SRs in temporal proximity to the conviction. In contrast, during juvenile criminal detention, immature coping strategies and absence of experience of detention may contribute to higher SRs as compared to adults. The period of pending transfer to adult detention that goes along with feelings of the unknown and uncertainty may be an additional risk period in juvenile criminal detention. Together, these aspects may result in balanced SRs in adolescent pre-trial and criminal detainees. Still, more studies are needed to clarify the reasons for age-specific differences. Trend in time During the study period, SRs in adolescent and young adult detainees declined over time. The decline of SRs in
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adolescent prisoners is not an age-specific phenomenon, as falling SRs were reported for male prisoners, when analysing all groups of age in sum based on the same set of data [27]. Also in the general population, decreasing SRs were found in adolescents. The trend in time was not significantly different in the detained adolescent population compared with adolescents in the general population, resulting in stable relative risks over time. Strengths and limitations The strengths of this study include the nationwide total survey with its long period of record as well as the data of two control groups that were carefully matched by calendar year, gender and age. The weakness of the study includes all aspects of a retrospective study approach.
Conclusion Detention was associated with a 23-fold greater suicide risk in adolescents and young adults in Germany compared to the age-adapted general population. RR was three times greater in young prisoners than in adult prisoners. Gender distribution of suicide did not differ significantly between both age groups. The modus of detention needs to be considered as an age-specific risk factor: whereas pre-trial detention was a common risk factor in both age groups, criminal detention was much stronger associated with suicide in young offenders compared to adults. These aspects need to be taken into account in future guidelines and preventive strategies to reduce suicide in prison more effective. Acknowledgments We gratefully acknowledge the skilful support by Urban Janisch (Kamenz, Germany) for help with data access. Conflict of interest of interest.
The authors declare that they have no conflict
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ORIGINAL CONTRIBUTION
National total Survey of German adolescent Suicide in Prison D. Radeloff • T. Lempp • E. Herrmann M. Kettner • K. Bennefeld-Kersten • C. M. Freitag
•
Received: 16 February 2014 / Accepted: 26 May 2014 / Published online: 22 June 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Incarcerated adolescents are a high-risk group for suicidal behaviour, but data on completed suicide are scarce in this population. The present study aimed at calculating relative risks (RR) of suicide in detention and identifying age-related risk factors. We compared data of a German national total survey of completed suicide of young detainees (14 to \21 years, N = 79) during the years 2000–2010 with age- and gender-adjusted suicide deaths in non-incarcerated adolescents (N = 3,484) and incarcerated adults (N = 781). Prison suicide accounted for 2.3 % of all suicide deaths in adolescents, but only 0.1 % of this age group was detained. The RR = 23.0 for adolescent suicide in detention exceeded the RR = 7.7 of adults by far. In adults, suicide rates in pre-trial detention was fivefold higher than in criminal detention; suicide rates were more balanced in adolescent detainees. Our results
D. Radeloff and T. Lempp contributed equally to this work. D. Radeloff (&) T. Lempp C. M. Freitag Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Goethe University of Frankfurt, Deutschordenstrasse 50, 60528 Frankfurt, Germany e-mail: [email protected] E. Herrmann Department of Medicine, Institute of Biostatistics and Mathematical Modeling, Goethe University Frankfurt, Frankfurt, Germany
underline the need for age-specific suicide prevention strategies in detention. Keywords Suicide Detention Risk assessment Mortality Conduct disorders Community mental health Abbreviations SR Suicide rate = suicide deaths per 100,000 person years RR Relative risk = ratio of the probability of an event occurring in an exposed group to the probability of the event occurring in a comparison group Group YP Adolescents (14 to \21 years of age) in criminal detention or pre-trial detention (p = prison) Group YGP Adolescents (14 to \21 years of age) in the general population (GP) outside correctional facilities Population Group YP ? Group YGP = adolescents (14 Y to \21 years of age) Group AP Adults (C21 years of age) in criminal detention or pre-trial detention (p = prison) Group AGP Adults (C21 years of age) in the general population (GP) outside correctional facilities Population Group AP ? Group AGP = adults A (C21 years of age)
M. Kettner Institute of Forensic Medicine, University of Saarland Medical School, Homburg/Saar, Germany
Introduction
K. Bennefeld-Kersten Criminological Services, Institute of Justice in Lower Saxony, Celle, Germany
In most western countries, suicide is the second or third leading cause of death among people 15–20 years old
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[1–3], and prevention has been challenging [4]. Incarcerated adolescents constitute a high-risk group for suicidal behaviour, and completed suicide was reported to be the leading cause of death in juvenile justice facilities [5]. Different reasons may contribute to the elevated suicide behaviour in young offenders. First, a high percentage of incarcerated youth shows characteristics, which are associated with high risk for suicide in the general population, for example substance abuse or mental disorders [6–8]. Second, additionally to this ‘imported’ risk profile, facility environment itself may contribute to an elevated suicide risk in confinement, as inhabitants are challenged by stressful conditions [5, 9]. Most likely due to a combination of these factors, suicidal ideation, plans and attempts are much more common in incarcerated youth compared to data from age-adapted general population [10–12]. While there is a comprehensive body of the literature on suicidal ideation and suicide attempts in adolescent inmates, studies on completed underage prison suicide are scarce. It is far from resolved, if suicide attempters and suicide completers are comparable with regard to psychopathology and risk factors [13, 14]. To the best of our knowledge, only one study [15] provides robust estimates of relative risks (RR) of teenage suicide in detention, and reported an 18-fold increased risk compared to the general population in Great Britain. Other studies reported a threefold, respectively, 4.6-fold increased risk [5, 16], but lacked precisely agematched data of the general population. The present study includes all known cases of completed suicide of adolescents and young adults (14 to \21 years), committed in German pre-trial and criminal detentions during the years 2000–2010. To provide robust RRs of adolescent suicide in detention and to describe age-specific risk factor profiles, data were compared with epidemiological data on incarcerated and non-incarcerated agematched adolescents and young adults, and on incarcerated adults (C21 years of age). We hypothesize (1) that detained German adolescents will show an increased suicide risk compared to non-incarcerated adolescents, (2) that RRs for suicide in detention will be greater in adolescents than in adults, and (3) that adolescent suicide rates will show age-related specifics regarding potential risk factors like gender or modus of detention.
Methods German youth-crime laws and prison system Across western countries, the age of criminal responsibility (the age at which the criminal justice system can prosecute a child or adolescent for a crime, as it is considered capable of understanding the wrongfulness of its conduct) and the
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age of criminal majority (the age at which the criminal justice system processes offenders as adults) vary considerably [17]. Most European countries have defined ages of criminal responsibility at between 13 and 16 years, whereas Cyprus assume criminal responsibility at the age of 7 years and the British legal system comprises varying ages (Scotland at 8 years; Northern Ireland, England and Wales at 10 years). The age of criminal majority is 18 in most European countries [17]. According to German law, the age of criminal responsibility is 14 years and there is a particular criminal law relating to young offenders between 14 and \18 years. Between 18 and 21 years of age, the courts have the provision to transfer offenders to the juvenile criminal law, depending on emotional, mental, and intellectual maturity [18]. Individuals who are 21 years old or older are judged as fully criminal responsible irrespective of possible maturational lags and are usually detained in correctional institutions for adults. Based on this differentiation, we studied 14 year to \21-year-old individuals as one group and compared these with adults aged 21 years and above. Data RRs for prison suicide were calculated based on: (1) the number of suicide deaths, and (2) the number of persons in justice facilities, (3) the number of suicide deaths, and (4) the number of persons in the general population. Data were obtained for comparable age strata, gender and time periods. Age strata were chosen as described above. Data were obtained for the 11-year period, 2000–2010. Adolescents and young adults were merged and labelled Population Y (Youth and Young Adults, 14 to \21 years), comprising minors and young adults in pre-trial detention or criminal detention (Group YP, p = prison) and those in the general population outside correctional facilities (Group YGP, GP = general population). Population A (Adults) consisted of adults who were at least 21 years of age, comprising pre-trial and criminal detainees (Group AP) and adults in the general population outside correctional facilities (Group AGP). In Germany, every state (Bundesland) is obliged to report all cases of suicide in prison. On a national level, data of committed suicides in incarcerated adolescents and adults were collected by one of the co-authors (KBK) by analysing the reports of unusual events of all pre-trial and criminal detentions in Germany retrospectively in the given time period at the Kriminologischer Dienst des Bildungsinstituts des niedersa¨chsischen Justizvollzuges in Celle/ Germany. Data from forensic psychiatry departments were not taken into account in this study. Data on demographic characteristics of individuals placed in correctional facilities in Germany were provided
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by the biannual census of the Federal Statistical Office Germany. Census data provide the number of inmates on two predefined dates per year, which were used to calculate the number of person years spent in detention during the study period. In this study, we compared person years spent inside and outside of correctional facilities. General population annual suicide deaths and annual population census data were obtained from the scientific section of the Federal Statistical Office Germany (Forschungsdatenzentrum der Statistischen Landesa¨mter, Duesseldorf, Germany). The study was approved by the ethics committee of the medical faculty of Goethe University Frankfurt, Germany and has been performed in accordance with the ethical standards of the Declaration of Helsinki and its later amendments.
Results
Statistical methods
During the 11-year study period, 733,041 person years were spent in detention in Germany covering all age groups. Group YP spent 69,863 person years in detention. In Group YP, 66,844 person years (95.7 %) were spent by male prisoners, and 3,019 (4.3 %) person years were spent by female prisoners. In pre-trial detention, 25,004 (35.8 %), and in criminal detention, 44,859 (64.2 %) person years were spent. Group AP spent 663,178 person years in detention; 625,473 (94.3 %) person years accounted for male prisoners, 37,705 (5.7 %) person years accounted for female prisoners. In Group AP 137,721 (20.8 %) person years were spent in pre-trial detention, and 525,457 (79.2 %) person years were spent in criminal detention.
Data were analysed with R (Version 3.0.2, URL:http:// www.R-project.org; [19, 20]). Suicide deaths inside and outside detention as well as the number of person years spent inside and outside detention were given in 2 9 2-tables stratified for age, gender and modus of confinement. Data were tested for an association between suicide and imprisonment with the Chi-square/Fisher exact test. Suicide rates (SR = number of suicides/number of 100,000 person years) and relative risks (RR = SR in exposed population/SR in non-exposed population) were calculated for the imprisoned and general population stratified by age (Population Y, A), gender and modus of confinement (pre-trial detention, criminal detention). To test for differences in the association between suicide and imprisonment between both age groups, 2 9 2-tables of Group YP and Group AP were compared, using the Tarone test for heterogeneity. Values of P \ 0.05 were considered significant; values P \ 0.10 were considered as a trend. To test for age specificity of risk factors (gender, modus of confinement), 2 9 2-tables for both age groups of prisoners were compared. First, 2 9 2-tables with the variables gender (male/female) and suicide (suicide/no suicide) were compared, using the Tarone test for heterogeneity. In a second step, 2 9 2-tables with the variables modus of confinement (pre-trial detention, criminal detention) and suicide were compared using the same approach. Trends in time were calculated for adolescents and young adults in detention and in the general population using linear regression with SRs on time period. Also, relative risks for adolescent suicide in detention were tested for time trends.
In Population Y prison suicide accounted for 2.3 % of all suicides, but only 0.1 % of this age group was detained. In Population A prison suicide accounted for 0.7 % of all suicides, albeit only 0.1 % of this age group was in detention. Between 2000 and 2010, the sum of person years spent inside or outside of correctional facilities by the general population (C14 years of age) was 785,124,951. Population Y spent 70,973,545 person years in the examined time period. Among these, 39,606,661 person years accounted for minors (\18 years). In Population A, 714,151,406 person years were spent in total. Population in detention
Suicide within detention In Group YP (adolescent prisoners), 79 cases of prison suicide occurred during the study period. All cases of suicide were male. Among them, 36 suicides (45.6 %) occurred in pre-trial detention and 43 (54.4 %) occurred in criminal detention. In group YP, the SR was 113.1 (minors: 83.94). SR in males was 118.2, in females 0.0. SR in pretrial detention and criminal detention was 144.0 and 95.9, respectively. In Group AP (adult prisoners), the number of suicides was 781. Among them, in 763 (97.7 %) cases gender was male and in 18 (2.3 %) cases, gender was female. N = 441 suicides (56.5 %) happened in pre-trial detention and 340 (43.5 %) in criminal detention. In Group AP, the SR was 117.8. In males, SR was 122.0; in females SR was 47.7. SR in pre-trial detention and criminal detention was 320.2 and 64.7, respectively. Please consider Table 1 as a summary of SRs in detention.
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Table 1 Suicide rates (SR) and relative risks (RR) in incarcerated and non-incarcerated adolescents and adults Gender Both genders
Adolescents
Detention No detention
Adults
Detention No detention
Males
Adolescents Adults
Females
Adolescents Adults
Detention
SR
P (v2/fisher)a)
RR (95 % CI)
P (Tarone)
113.1
\0.001
23.0 (17.2, 30.8)
\0.001
\0.001
7.7 (7.1, 8.4)
\0.001
16.0 (11.9, 21.4)
\0.001
5.2 (4.8, 5.7)
1
–
\0.001
6.1 (3.3, 11.1)
4.9 117.8 15.3 118.2
No detention
7.4
Detention No detention
122.0 23.4
Detention
0.0
No detention
2.3
Detention No detention
47.7
\0.001
0.515
7.8
SR suicide rate (number of suicides/100,000 person years), RR relative risk, CI confidence interval, Tarone Tarone test for heterogeneity a
Fisher exact test was conducted when cells with expected zero counts were present in underlying 2 9 2-tables
Population and suicides outside detention Outside correctional facilities, 70,903,603 person years (males: 36,306,347, 51.2 %; females: 34,598,992, 48.8 %), were spent by adolescents and young adults. In Group YGP, 39,591,160 person years (males: 20,313,280 person years, 51.3 %; females: 19,277,880 person years, 48.7 %) accounted for minors. In Group AGP, 713,487,447 person years (males: 344,406,324 person years, 48.3 %; females: 369,081,123 person years, 51.7 %) were spent. In Group YGP, the total number of suicides was 3.484; 1.210 suicides occurred in minors (\18 years; 34.7 %). In 2,686 (77.1 %) cases, gender was male, in 798 (22.9 %) cases, gender was female. In Group YGP, the SR was 4.9 (minors: 3.1). SR in males was 7.4 and in females the SR was 2.3. In Group AGP, the total number of suicides was 109,472. Among these, 73.9 % were male (N = 80,846) and 26.1 % were female (N = 28,966). In Group AGP, the SR was 15.3. SR in males was 23.4 and in females SR was 7.8. Please consider Table 1 for SRs in the general population. Relative risks and group comparisons Comparing Group YP and Group YGP, a RR of 23.0 for completed suicide was observed which equals to a 23-fold increased suicide risk in young prisoners when compared with the same age group of the general population. In minors, the RR was 27.5. Comparing Group AP and AGP, the RR was 7.7, which equals to a 7.7-fold increased risk of suicide in prison in this age group. In detained adolescents and young adults, the RR for suicide was significantly
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greater than in incarcerated adults (Tarone test for heterogeneity: v2 = 93.38, df = 1, P \ 0.001). Gender Male gender was associated with suicide in all groups (Group YP: df = 1, P = 0.051 (Fisher test); Group AP: v2 = 603.45, df = 1, P \ 0.001; Group YGP: v2 = 992.62, df = 1, P \ 0.001; Group AGP: v2 = 28,608.38, df = 1, P \ 0.001). The gender-specific RR (Group YP compared to Group YGP) was 16.2 for males and 0.00 for females. In adults, the RR (Group AP compared to Group AGP) was 5.2 for males and 6.1 for females, which indicates a roughly equal RR between the gender groups. Indeed, the association between gender and prison suicide did not differ significantly between age groups (Tarone test for heterogeneity: v2 = 1.40, df = 1, P = 0.237). Modus of confinement SRs in pre-trial and criminal detention are given in Table 2. In pre-trial detention, the relative risk in Group YP was RR = 29.3 (Group AP : 20.9) and in criminal detention the RR was 19.5 (Group AP: 4.2). In the imprisoned population, the modus of confinement had a different influence on suicides in Group AP as compared to Group YP (Tarone test for heterogeneity: v2 = 27.42, df = 1, P \ 0.001): In adult prisoners, suicide was associated stronger with pre-trial detention (SR = 320.2) than with criminal detention (SR = 64.7), whereas in adolescents and young adults, the influence of modus of confinement was more balanced (pre-trial detention: SR = 144.0; criminal detention:
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Table 2 Suicide rates (SR) in pre-trial and criminal detention in incarcerated adolescents and adults Modus of confinement Adolescents
Adults
SR
P (v2)
RR (95 % CI)
P (Tarone)
Pre-trial detention
144.0
0.090
1.5 (0.8, \0.001 2.7)
Criminal detention
95.9
Pre-trial detention
320.2 \0.001
Criminal detention
64.7
4.9 (4.1, 6.0)
SR suicide rate (number of suicides/100,000), RR relative risk, CI confidence interval, Tarone Tarone test for heterogeneity
SR = 95.9). Comparing Population Y and Population A, the association between criminal detention and suicide was significantly stronger in Population Y (Tarone test for heterogeneity: v2 = 107.15, df = 1, P \ 0.001). Trend in time In adolescents, all cases of suicides were male. Therefore, trend over time for SRs in detention and in the general population were calculated for male gender. There was a significant decrease of SRs in adolescent detainees (Group YP: R2 = 0.38, t = -9.3, df = 9, P = 0.042) and adolescents in the general population (Group YGP: R2 = 0.55, t = -0.29, df = 9, P = 0.009). No significant trend over time was found for RR of suicide in adolescent detainees (Population Y: R2 = -0.173, t = -0.71, df = 9, P = 0.203).
Discussion This study has shown the following main findings: (1) The RR for suicide of adolescents in detention in Germany is 23.0, indicating a 23-fold increased risk for suicide of this group compared to the age-matched general population. (2) Compared to adults (RR = 7.7), the RR was significantly greater in adolescents. (3) The association between suicide and modus of confinement was age-dependent: In the imprisoned population, the influence of criminal detention and pre-trial detention on suicide was roughly equal in adolescents, whereas in adulthood, suicide was associated stronger with pre-trial detention.
equivalent general population was in confinement. The RR for suicide of adolescent and young adult detainees was 23.0. This is in accordance with our first hypothesis, and proves that young prisoners constitute a high-risk group for completed suicide. Men are by far overrepresented in imprisoned populations (in this study, 94.4 % of the detainees were male), and male gender is associated with a higher suicide risk. Thus, male gender contributes to a high RR in detention. As male-specific RR is also high in young detainees (RR = 16.0), additional factors may contribute to the elevated suicide risk in young prisoners: Firstly, many detainees are high-risk adolescents who would even have been at a high risk for suicide without being incarcerated. For example, impulsive character traits and mental disorders [6, 7], substance abuse [21] and history of prior suicide attempts [10] are substantially more common in adolescents in detention compared to the age-equivalent general population. Secondly, the detention environment itself (e.g. separation from family and pears, loss of control and perspective, feelings of shame and guilt) might contribute to a high risk of suicide compared to the adolescents’ environment outside detention [5, 9, 22]. To our knowledge, only one study [15] provides robust data of suicide risk in adolescent prisoners, remarkably standard mortality ratios were calculated. Male prisoners in the United Kingdom showed an 18-fold increased suicide risk between 15 and \18 years of age, and a sixfold increased suicide risk between 18 and 20 years. No adolescent female suicide occurred in the examined population [23]. As data on adolescent suicide are always based on a small number of prison suicides, the authors recommended a replication of their findings. Our results replicated an elevated RR in young prisoners. Two other studies reported lower RRs in contrast to our results: Gallagher and Dobrin reported a threefold [5] and Memory a 4.6-fold [16] increase in suicide risk in adolescent detainees. In both US–American studies, the number of included suicide cases was low (Gallagher: N = 20, Memory: N = 28), and no precise age matching or calculation of gender-specific RRs were conducted. Gallagher examined suicide rates in a mixed sample of detainees in both, open and secure juvenile justice facilities in the US. The smaller RR found in this study might also reflect lower suicide rates in open juvenile correction facilities, which were excluded in our study. Comparison of RR in adolescents and adults
RR in young detainees Between 2000 and 2010, prison suicides accounted for 2.2 % of all suicide deaths in Germany in the age band from 14 to \21 years, whereas only 0.1 % of the age-
The association between suicide and detention was significantly stronger in adolescents compared to adults, reflected by a higher RR in the younger age group. This finding is in accordance to previous studies reporting
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standard mortality ratios of different age groups in detention [15, 23]. Standard mortality ratios in male minor detainees were highest of all age groups followed by male young adults (18–21 years). In agreement, in our study, RR was highest for male minors and second highest in male young adults. As data in adolescents are based on a small number of suicides in both studies, results need to be treated with caution. The difference of RR between adolescents and adults was mainly driven by different SRs in the general population with lower rates in adolescents, whereas SRs in detention were roughly equal between adolescents and adults. Different factors might contribute to the higher RR in young prisoners relative to adult prisoners. First, the high RR in adolescent detainees might be influenced by a disproportionately high amount of late adolescents (18–21 years) in prison compared to the general population. Secondly, age-related differences in criminal law result in age-specific characteristics of imprisoned populations, e.g. regarding duration of detention or severity of offences [24]. Thirdly, young detainees could be particularly challenged by detention environment due to a higher vulnerability to detention-specific stressors (e.g. separation from family) and immature coping strategies. Compared to adult detainees, the amount of prisoners experienced with prior detention is lower in adolescent detainees [24]. Gender The difference between RR of all detainees compared to gender-specific RRs emphasizes the necessity to take characteristics of the incarcerated and the general population into account when calculating or comparing RRs of high-risk populations. RR for male prisoners in adolescence was 15.6. No female prisoners committed suicide in this age group. This is in accordance with other studies, reporting that in teenage years, prison suicide is committed mainly by males [9, 15, 23]. The lack of female adolescent suicide reflects the high percentage of male prisoners in confinement: As the portion of incarcerated females in this age group is low, the calculation of underage female suicide ratios fails for statistical reasons [23]. In all groups, male gender was associated with suicide (in adolescent prisoners, this association was found only as a trend, possibly due to a small sample size). As the association between gender and suicide was not significantly different between age groups, gender can not be considered as an age-specific risk factor. Because data on female suicide in confinement is rare, we suggest a metaanalytic approach on pooled data in future work.
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Modus of confinement In both age groups, detention was associated with an elevated risk for suicide. In both young detainees and adults, SRs were higher in pre-trial detention compared to criminal detention. To our knowledge, this is the first study that compared RRs for adolescent and young adult suicide in pre-trial versus criminal detention. Previous studies reported that juvenile prison suicide characteristics were influenced by the modus of detention as suicide rates differed between open and secure juvenile correction facilities with lower rates in open facilities [5, 16]. The time point of suicide was influenced by the modus of detention: in detention centres most suicides happened within the first week after confinement compared to less secure juvenile correctional facilities [25]. Still, results were based on small samples and differing methodological frameworks, leading to partly contradictory results between studies [16, 25]. In our study, we found balanced SRs in adolescent pretrial (SR = 144.0) and criminal detainees (SR = 95.9), whereas in adulthood, the SR in pre-trial detention (SR = 320.2) was fivefold greater than in criminal detention (SR = 64.7). Thus, in young prisoners criminal detention must be considered as an age-specific risk factor nearly as important as pre-trial detention. This is in accordance with our third hypothesis. Still, this study does not provide information about the reasons for this finding, thus causations stay speculative. Two high-risk periods for suicide in pre-trial detention were described [26]: frequently, suicides occur at a very early stage of confinement or within 3 days of a court appearance, especially when a conviction and harsh sentencing can be anticipated. Speculative, in juvenile pre-trial detention, the level of care may be higher during reception and first night procedures than in adult justice facilities. Less harsh penalties due to youth crime law may result in lower SRs in temporal proximity to the conviction. In contrast, during juvenile criminal detention, immature coping strategies and absence of experience of detention may contribute to higher SRs as compared to adults. The period of pending transfer to adult detention that goes along with feelings of the unknown and uncertainty may be an additional risk period in juvenile criminal detention. Together, these aspects may result in balanced SRs in adolescent pre-trial and criminal detainees. Still, more studies are needed to clarify the reasons for age-specific differences. Trend in time During the study period, SRs in adolescent and young adult detainees declined over time. The decline of SRs in
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adolescent prisoners is not an age-specific phenomenon, as falling SRs were reported for male prisoners, when analysing all groups of age in sum based on the same set of data [27]. Also in the general population, decreasing SRs were found in adolescents. The trend in time was not significantly different in the detained adolescent population compared with adolescents in the general population, resulting in stable relative risks over time. Strengths and limitations The strengths of this study include the nationwide total survey with its long period of record as well as the data of two control groups that were carefully matched by calendar year, gender and age. The weakness of the study includes all aspects of a retrospective study approach.
Conclusion Detention was associated with a 23-fold greater suicide risk in adolescents and young adults in Germany compared to the age-adapted general population. RR was three times greater in young prisoners than in adult prisoners. Gender distribution of suicide did not differ significantly between both age groups. The modus of detention needs to be considered as an age-specific risk factor: whereas pre-trial detention was a common risk factor in both age groups, criminal detention was much stronger associated with suicide in young offenders compared to adults. These aspects need to be taken into account in future guidelines and preventive strategies to reduce suicide in prison more effective. Acknowledgments We gratefully acknowledge the skilful support by Urban Janisch (Kamenz, Germany) for help with data access. Conflict of interest of interest.
The authors declare that they have no conflict
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Copyright of European Child & Adolescent Psychiatry is the property of Springer Science & Business Media B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
